Hangman fracture

Last revised by Dr Yusra Sheikh on 29 Sep 2021

Hangman fracture, also known as traumatic spondylolisthesis of the axis, is a fracture which involves the pars interarticularis of C2 on both sides, and is a result of hyperextension and distraction.

These injuries account for 4-7% of all cervical spine fractures and up to 22% of axis fractures 6.

Post-traumatic neck pain after a high-velocity hyperextension injury is the most common presentation. Neurological impairment is seen only in 25% of patients.

This is known as a 'judicial lesion' as these are the forces delivered by a noose, which, contrary to most ill-informed depictions, was placed with the knot towards the side of the neck, next to the angle of the mandible/mastoid process.

This fracture is virtually never seen in suicidal hanging. Indeed, it was not even seen in many of those who were judicially hanged; asphyxiation being the usual mode of death. Major trauma in hyperextension, such as a high-speed motor vehicle accident, is, in fact, the most common association – especially in fatal cases.

The original classification system was described by Effendi 7, but the Levine and Edwards classification 8 which is a modified version of Effendi's system is the most commonly used system at the time of writing (April 2021).

  • bilateral lamina and pedicle fracture at C2
  • usually associated with anterolisthesis of C2 on C3

Extension of the fracture to the transverse foramina should be sought, raising the possibility of vertebral artery injury.

Treatment can be bracing or, more typically, internal fixation.

The term "hangman fracture" was introduced by Schneider in 1965 5. Strictly speaking, the fracture is misnamed and should more correctly be called "hangee" fracture. As a historical note, there are four methods of judicial hanging, and the process is more complicated than may be evident at first glance.

  • check for an extension to the transverse foramina and, if present, vertebral artery injury should be considered

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Cases and figures

  • Figure 1: Levine and Edwards classification
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  • Case 1: on lateral plain film
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  • Case 2: axial
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  • Case 2: sagital
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  • Case 3
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  • Case 4
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  •  Case 5: plain film
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  •  Case 5: CT-scan
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  • Case 6
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  • Case 7
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  • Case 8: Hangman and extension teardrop fractures
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  • Case 9
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  • Case 10: with right vertebral artery traumatic pseudoaneurysm (Biffl grade 3)
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  • Case 11
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